Atrial fibrillation (AF) Patient information

Transcription

1 AF A Atrial fibrillation (AF) Patient information Providing information, support and access to established, new or innovative treatments for Atrial Fibrillation Registered Charity No

2 Glossary Antiarrhythmic drugs a group of drugs used to restore the normal heart rhythm. Anticoagulant a group of drugs which help to thin the blood. Arrhythmia Heart rhythm disorder. Arrhythmia Nurse Specialists A nurse who is trained in heart rhythm disorders. Atrial fibrillation (AF) Irregular heart rhythm. Atrial flutter A rhythm disorder characterised by a rapid but regular atrial rate but not as high as atrial fibrillation. Cardiologist A doctor who has specialised in the diagnosis and treatment of patients with a heart condition. Cardioversion A therapy to treat atrial fibrillation or atrial flutter which uses a transthoracic electrical shock to revert the heart back into a normal rhythm. Catheter ablation A treatment which destroys small areas inside the heart which are causing the AF. Dyspnoea A medical term for shortness of breath. Echocardiogram An image of the heart using echocardiography or soundwave-based technology. An echocardiogram (nicknamed echo ) shows a three-dimensional shot of the heart. Electrocardiogram or ECG (sometimes EKG) A representation of the heart s electrical activity in the form of wavy lines. An ECG is taken from electrodes on the skin surface. Contents Introduction The heart during normal rhythm ( sinus rhythm ) What is atrial fibrillation? What causes atrial fibrillation? What are the symptoms of atrial fibrillation? Are there different types of atrial fibrillation? How do I get to see the right doctor to treat my AF? What are the risks of atrial fibrillation? Tests and investigations Treatment of atrial fibrillation Drug treatments Non-drug treatments Stroke prevention Alternatives to anticoagulation Anticoagulants Antiplatelets Arrhythmia Nurse Specialists 2

3 Electrophysiologist (EP) A cardiologist who has specialised in heart rhythm disorders. Heart failure The inability (failure) of the heart to pump sufficient oxygenated blood around the body to meet physiological requirements. Rate control of AF A medical approach to treating atrial fibrillation which does not treat the AF itself, but rather attempts to slow the rapid ventricular response to the fibrillating atria (increased heart rate). Since a fast rate is what is most associated with symptoms, this provides symptomatic relief. Rhythm The pattern of cardiac activity. Strictly speaking, the heart has both a rate (how fast it beats) and a rhythm (the pattern of activity). Rhythm includes the ratio of atrial to ventricular activity. Sinus rhythm Normal rhythm of the heart. Stroke A medical condition which is now referred to as a brain attack where the brain is deprived of oxygen. Blockage of blood flow can occur when a blood clot breaks free, travels through the circulatory system to the brain and gets lodged in blood vessel long enough to cause damage to a section of the brain. Strokes can vary in severity from transient (TIA) to very severe. Syncope A medical term for passing out from lack of oxygen going to certain areas of the brain. 3

4 Introduction Atrial fibrillation (AF) is the most common heart rhythm disturbance encountered by doctors. It affects approximately 1 million people in the UK alone. It can affect adults of any age, but is more common as people get older. In the over-75 age group it affects about 10% of people. AF accounts directly for around 100,000 hospital admissions and is associated with a further 575,000 hospital admissions per year. AF consumes 1% of the NHS total budget. Left untreated or poorly monitored AF can lead to serious complications such as heart failure and stroke. Sinus Node Atrium The heart and normal conduction AV Node PulmonaryVeins The heart during normal rhythm ( sinus rhythm ) The heart is a muscular pump, which delivers blood containing oxygen to the body. It is divided into two upper chambers (atria), which collect blood returning via the great veins, and two lower chambers (ventricles), which pump blood out to the lungs and through the aorta (main artery) to the rest of the body. Normally, the heart beats in a regular, organised way, at a rate of beats per minute. This is because it is driven by the sinus node, a specialised group of cells situated in the right atrium, which emits electrical impulses. The sinus node is sometimes referred to as the heart s natural pacemaker. These electrical impulses spread through the atria and then into the ventricles via a connecting cable (the AV node ). The sinus node controls the timing of the heart, according to the needs of the body. Conducting pathways 2012 (Figure 1) Ventricle 4

5 An example of this is during exercise, when the heart rate speeds up. When the heart is beating normally like this, we refer to it as sinus rhythm, or normal sinus rhythm. What is atrial fibrillation? Atrial fibrillation (AF) occurs when chaotic electrical activity develops in the upper chambers of the heart or atria, and completely takes over from the sinus node. As a result the atria no longer beat in an organised way, and pump less efficiently. The AV node will stop some of these very rapid impulses from travelling to the ventricles, but the ventricles will still beat irregularly and possibly rapidly. This may contribute to symptoms of palpitations, shortness of breath, chest discomfort, light headedness, fainting or fatigue. The goal of treatment in AF is to restore the heart s normal rhythm and if this is not possible then to slow the irregular heart rate, to alleviate symptoms and prevent complications of AF related to stroke and heart failure. Who gets atrial fibrillation? There is no typical atrial fibrillation patient. Atrial fibrillation occurs in men and women, in all races, and can occur at any age. While it can run in the family, most people diagnosed with atrial fibrillation will not have a family history of the disease. Some events and diseases may make AF more likely, but it can also occur without warning. 5

6 What causes atrial fibrillation? Atrial fibrillation is related to age; the older you get, the more likely you are to develop it. Men and women are equally susceptible to the disease. Atrial fibrillation is frequently noted after an open heart operation. Other conditions or diseases can also increase your risk of getting atrial fibrillation. This does not mean that atrial fibrillation always develops but the risk does increase. Below are several conditions associated with atrial fibrillation: High blood pressure Coronary heart disease Mitral valve disease (caused by rheumatic heart disease, valve problems at birth, or infection) Congenital heart disease (abnormality of the heart present since birth) Pneumonia Lung cancer Pulmonary embolism Overactive thyroid Carbon monoxide poisoning In addition, alcohol and drug abuse or misuse may predispose you to atrial fibrillation. While your risk of atrial fibrillation goes up with the problems mentioned above, many people develop atrial fibrillation for no explainable reason. What are the symptoms of atrial fibrillation? Symptoms of AF include: Palpitations which may be rapid Tiredness Shortness of breath Dizziness Chest pain Some people with AF do not have any symptoms, and it may only be discovered at a routine medical examination or following an admission to A&E with another condition. The easiest way to detect AF is to feel your pulse! 6

7 Are there different types of atrial fibrillation? Yes, early in the disease, atrial fibrillation is often intermittent, meaning that it can come and go without warning and you may go long periods of time between spells. When atrial fibrillation first occurs, the early episodes may be brief and cause very mild symptoms. In fact, some people with this early-stage atrial fibrillation may not even know they have it. AF falls into one of three categories that describe the progression of the disease, ranging from occasional episodes to the complete absence of a normal heart rhythm: 1. Paroxysmal AF multiple episodes that cease within seven days without treatment, 2. Persistent AF episodes lasting longer than seven days, or less than seven days when treated, 3. Permanent AF when the presence of AF is accepted by the patient and the physician and strategies to restore sinus rhythm are not being pursued. How do I get to see the right doctor to treat my AF? Initially your general practitioner may arrange some investigations if you consult them about your symptoms. Depending on the results of these investigations you may be referred to a cardiologist (heart specialist) who may or may not have a specialist interest in heart rhythm disorders. After appropriate diagnosis, some patients will respond to medication and in this case it may be that no further treatment will be required. You may be referred to a cardiologist who specialises in heart rhythm disorders usually called an electrophysiologist (EP) this type of doctor will offer ablation treatments, and some will perform large numbers of ablation procedures for atrial fibrillation. If you are seen by a general cardiologist you may be referred on to see an electrophysiologist, but if this is not offered you can request specialist referral from either your general practitioner or cardiologist. The outcomes from atrial fibrillation ablation, as with many other procedures, are generally better in more experienced hands. Before proceeding with ablation you should ask the electrophysiologist about his or her personal level of experience and results. 7

8 A team approach to atrial fibrillation ablation is important and you should also ask about the number of cases performed in the hospital where you will have the procedure. An electrophysiologist who has a specialist interest in atrial fibrillation ablation will usually perform over 50 procedures of this type per year. For further information on local EPs contact Atrial Fibrillation Association. To summarise, these are the services typically offered by each type of doctor: (1) General Practitioner - overall responsibility for patient care and prescription of medication. May offer simple investigations and monitoring of anticoagulation therapy. (2) General Physician / Cardiologist investigation of heart disease, initiation and monitoring of drug treatment, cardioversion. (3) Electrophysiologist all aspects of heart rhythm diagnosis and treatment, including ablation procedures. Some electrophysiologists perform a high volume of ablation procedures for atrial fibrillation. What are the risks of atrial fibrillation? The main risk associated with AF is stroke. This occurs because the atria are fibrillating and not beating in a co-ordinated way. As a result, the blood in the atria can become stagnant and then does not flow through the heart smoothly. This causes blood cells to stick together and form a clot which can travel (embolise) to the brain and result in a stroke. Having an uncontrolled (high) heart rate for long periods of time (weeks or months) can damage the heart and you should check with your doctor that your heart rate is controlled adequately. In extreme cases, often when the rate is very fast or when it happens in a damaged heart, AF can cause heart failure, which means that the heart becomes weak as a result of the rapid rhythm. As the heart weakens, there can be a build up of pressure back into the lungs and this affects the normal breathing pattern. In general, AF is not considered a life threatening condition as long as it is treated appropriately. 8

9 Tests and investigations First, it is important to check that you do actually have AF. This is confirmed by a heart tracing called an electrocardiogram (ECG). The ECG may be a simple recording made at the time of your visit, or a continuous monitor, worn for 24 hours or more, to look for episodes of AF. Heart monitors are painless and allow your doctor to record your rhythm for several days during various activities in an attempt to diagnose the condition of atrial fibrillation. You may need to have an echocardiogram (an ultrasound scan of the heart) which can assess the structure and overall function of the heart and you may also need to have blood tests. Treatment of atrial fibrillation Many factors can influence the best therapy for your individual case. The good news for people with atrial fibrillation is that there are a greater range of treatments and more effective treatments than ever before. Drug treatments Currently, drugs are the most common treatment for AF, and have the aim of alleviating symptoms and reducing the likelihood of stroke. Commonly prescribed medicines include bisoprolol, verapamil, diltiazem, flecainide, sotalol, amiodarone, dronedarone and digoxin. These drugs are used in two different ways. Some are used to restore the normal heart rhythm, these are known as anti-arrhythmic drugs. They work by blocking specific channels in the cardiac cell. Beta blockers are commonly used to slow the heart rate and are effective in active patients with better exercise capacity. In some patients with infrequent sustained episodes of AF, flecainide or propafenone may be given as a single dose at the beginning of the attack. This is known as the pill in the pocket method. However, this is only safe when patients are carefully trained to undertake this procedure and practice it first in the hospital setting. A booklet entitled Drug information for atrial fibrillation is available from Atrial Fibrillation Association. 9

10 NICE AF Guidance published in June 2014 recommends that drug therapies for symptom control are reviewed for effectiveness and any side effects within four weeks of being prescribed. Non-drug treatments In some individuals the episodes of atrial fibrillation are both severe and frequent, affecting their quality of life. If drug treatments do not work or cause unpleasant side effects, it may be necessary to offer a different solution. Physicians may elect to perform a cardioversion, a procedure in which an electric current is delivered through special gel pads positioned on the chest wall. This is done with the patient under either sedation or general anaesthetic. Cardioversion aims to shock the heart back into its regular rhythm. This is often done for patients with persistent AF. For some an additional procedure called catheter ablation may be performed to treat AF. This is done by passing long electrical wires to the heart via small tubes which are inserted into the vein at the top of the leg. Areas of the heart giving rise to atrial fibrillation can be ablated (cauterised) in order to restore normal (sinus) rhythm. Cauterisation or ablation eliminates the electrical signals of the tissue thus preventing them triggering AF. The National Institute of Health and Care Excellence (NICE) published updated guidance for AF in 2014 which clearly outlines the position of catheter ablation for those who have symptomatic AF where the symptoms are not adequately controlled on medication. Catheter ablation can successfully cure AF in up to 80-90% of patients although more than one procedure may be required to achieve this. The Catheter ablation for AF patients booklet is available from AF Association. If open heart surgery is required for a structural problem such as an abnormal heart valve in someone who also has AF then it is possible to perform ablation for AF at the time of surgery. 10

11 Stroke prevention In AF the chaotic electrical activity means that the atria (top chambers of the heart) no longer contract together but instead the muscle quivers like a bag of worms. A lack of efficient contraction means the blood within the atria can become stagnant and form clots. These clots can travel anywhere in the body, but most worryingly, they can travel to the brain and cause a stroke. Indeed the risk of stroke in AF is five times greater than in the normal sinus rhythm (regular heart rhythm). The NICE guideline of 2014 recommends that all people with AF, except those with no stroke risk factors (see below), should be offered anticoagulation therapy to reduce this risk of stroke. Alternatives to anticoagulation For many years it was thought that low dose aspirin, or other medication that affects the sticky clot-forming cells called platelets, could reduce the risk of clots forming in the atria and causing AF-related stroke. It was thought that aspirin would cause less bleeding than an anticoagulant. It is now clear that if aspirin reduces AF related stroke, it does this a very low levels. Furthermore, the bleeding risks of aspirin are very similar to the bleeding risk of an anticoagulant. It is for this reason that the NICE AF Guideline of 2014 removed any recommendation for the use of aspirin to reduce the risk of AF-related stroke. The new guideline clearly states: Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation. If a person is unable to tolerate an anticoagulant safely, their clinician may consider either the procedure known as left atrial appendage occlusion (see AFA factsheet Transcatheter closure of the left atrial appendage ), or dual antiplatelet therapy, which involves taking aspirin and clopidogrel together. However, dual antiplatelet therapy reduces the risk of AF-stroke only by up to 22% for a bleeding risk greater than that of aspirin alone. It is important for you to discuss the most appropriate therapy with your clinician. Aspirin may still be prescribed for another, non-af-related condition, such as a past heart attack or other problem with the circulation. 11

12 Anticoagulants Anticoagulants are far better than antiplatelets in reducing the risk of AF-stroke, and are as safe. Anticoagulants can reduce the risk of AF-stroke by at least 65%. For a long time, warfarin was the main anticoagulant available. It acts on the liver to prevent the formation of the proteins that go on to create fibrin. As our bodies have stores of these proteins, warfarin will only start to thin the blood efficiently after a few days. When you first start taking warfarin you will attend an anticoagulant clinic frequently so that your dose can be adjusted to your own needs. Most people find that once they are established on warfarin, their blood clotting potential, reflected as international normalised ratio (INR), remains relatively stable, and they need only attend the clinic every six or eight weeks. In order to keep your warfarin level stable, you have to watch out for certain things that may affect it. This includes alcohol, certain food items and other medication, including cough remedies, herbal cures and many other over-thecounter medications. If you are unsure of whether you can take a particular medication when on warfarin, you should seek advice of your doctor or local chemist. Since 2012, new approved anticoagulants have become widely available: dabigatran, rivaroxaban and apixaban, which work to inhibit thrombin, which is a factor contributing to the formation of fibrin. These have been approved by NICE since 2012 for stroke prevention in AF. They do not require monitoring with regular blood tests, and there are far fewer interactions with food and other medications than with warfarin, but at present their downside is that there is no specific way to reverse their effect. Having said this, the time that they are effective in the bloodstream is much shorter than for warfarin, and so a bleed would not last indefinitely. Factsheets about other new anticoagulants are available from AF Association. Please contact us for further details. 12

13 Antiplatelets The most common antiplatelets are aspirin and clopidogrel. They act upon the platelets circulating in the blood almost immediately. However, as platelets are not so vital for clot formation within the atria, antiplatelets are far less effective than anticoagulants at preventing AF-related stroke, only reducing the stroke risk in AF by 20%. NICE no longer recommend the use of aspirin alone in preventing AF-related stroke. National guidance recommends anticoagulants. Otherwise, if a person is unable to tolerate an anticoagulant safely, the clinician may consider either the procedure known as left atrial appendage occlusion (see AFA factsheet Transcatheter occlusion of the left atrial appendage ) or dual antiplatelet therapy, which involves taking aspirin and clopidogrel together. However, dual antiplatelet therapy reduces the risk of AF-stroke only by up to 22%. It is important for you to discuss the most appropriate therapy with your clinician. Aspirin may still be prescribed for another, non-af-related condition, such as a past heart attack or other cardiovascular problem. Which drug is best for me? The choice of which drug is best for you depends on:- (i) your personal risk of stroke and (ii) if any intervention like cardioversion or ablation are planned. A more detailed booklet Blood thinning in atrial fibrillation is available from Atrial Fibrillation Association. 13

14 Arrhythmia Nurse Specialists Many hospitals now employ Arrhythmia Nurse Specialists (ANS). The ANS is a dedicated point of contact and is available to offer you and your family support and guidance throughout the treatment of your arrhythmia. They work within Local and National frameworks to deliver the highest quality of care giving patients the appropriate information about their condition and how best it can be managed. For further information contact your local hospital. References: oxfordjournals.org/ content/12/10/1360. full.pdf+html European Society of Cardiology Guidelines on the Management of Atrial Fibrillation uk/nicemedia/ live/10982/30052/ pdf NICE guidelines on the management of atrial fibrillation, nicemedia/live/ 11194/31461/ pdf uk/nicemedia/live/ 14573/68046/ pdf 14

15 AF A Begin or renew your subscription! SUBSCRIPTION APPLICATION FORM Subscription to AF Association is free, but donations are gratefully received. Cheques should be made payable to AF Association. If you are interested in receiving information, becoming a volunteer or fundraiser, please do not hesitate to contact us. PLEASE PRINT: Patient Title: Mr / Mrs / Miss / Ms / Dr Full Name: Address: Postcode: Daytime Telephone no: Evening Telephone no: Date of Birth: Ethnicity: Carer Name: Tel: Address: Tick box if happy to receive newsletters and updates from AF Association Patient Diagnosed: Yes No Diagnostic tests done: Diagnosis: If diagnosed by whom: GP Geriatrician Cardiologist Paediatrician Name: Hospital/Medical Centre: Medication: Devices used: Registered Charity No: GIFT AID DECLARATION Please treat all qualifying gifts of money made as Gift Aid donations (please tick as applicable) today in the past 4 years in the future Title:... First name or initial(s):... Surname:... Full home address: Postcode:... Signature:... Date:... AF A Please return to: AF Association, PO Box 6219, Shipston-on-Stour, CV37 1NL Telephone info@afa.org.uk Registered charity No I confirm I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for each tax year (6 April to 5 April) that is at least equal to the amount of tax that all the charities or Community Amateur Sports Clubs (CASCs) that I donate to will reclaim on my gifts for that tax year. I understand that other taxes such as VAT and Council Tax do not qualify. I understand the charity will reclaim 25p of tax on every 1 that I have given since 6 April Please notify the charity or CASC if you wish to cancel this declaration, change your name or home address, or no longer pay sufficient tax on your income and/or capital gains. If you pay Income Tax at the higher or additional rate and want to receive the additional tax relief due to you, you must include all your Gift Aid donations on your self-assessment tax return or ask HM Revenue and Customs to adjust your tax code.

16 AF A Providing information, support and access to established, new or innovative treatments for Atrial Fibrillation AF Association PO Box 6219 Shipston-on-Stour CV37 1NL +44 (0)1789 info@afa.org.uk Registered Charity No Published May 2008 Reviewed August 2014 Planned Review Date August 2016 Atrial Fibrillation Association would like to thank all those who helped in the development of this publication. Particular thanks is given to Professor A John Camm, Dr Neil Davidson, Dr Matthew Fay, Angela Griffiths, Dr Matthew Ginks, Professor Richard Schilling, and Sandra Jackson. Trustees: Prof. A John Camm Mrs Jayne Mudd Prof. Richard Schilling AFA Medical Advisory Committee: Dr Matthew Fay Dr Adam Fitzpatrick Dr Andrew Grace Prof. Gregory YH Lip Mrs Angela Griffiths Dr Derek Todd Dr Andreas Wolff Professor Richard Hobbs Founder & CEO: Mrs Trudie Lobban MBE FRCP Edin Deputy CEO: Mrs Jo Jerrome endorsed by Please remember that this publication provides general guidelines only. Individuals should always discuss their condition with a healthcare professional. If you would like further information or feedback, please contact AF Association. Affiliate This booklet is intended for individuals affected by atrial fibrillation. Information within this booklet is based upon clinical research and patients experiences.